Background

Hospitalists know the importance of medications for VTE prophylaxis, but 12.7% of
prescribed doses were not administered in a study of 75 patients at Johns Hopkins Hospital, published in March 2018 by the American Journal of Health-System Pharmacy. Because the most commonly cited reason for nonadministration was patient refusal,
the Johns Hopkins VTE Collaborative decided to tackle the problem with patient education.

“Our first step was to ask patients what they wanted to learn,” said
Elliott R. Haut, MD, PhD, vice chair of quality, safety, and service in the department
of surgery at Johns Hopkins Medicine. After collecting patient input, the research
group developed a patient education bundle composed of a two-page form about blood-clot
prevention, a 10-minute video of patients' stories (shown on a hospital tablet, the
TV, or a patient's personal device), and in-person support from a nurse educator.

How it works

The intervention was tied into the hospital's electronic health record, which provided
real-time notifications to the study team when patients missed doses. After an alert,
a nurse educator from the study team spoke to the patient and bedside nurse for a
median of 10 and two minutes, respectively, and offered patients all three parts of
the education bundle, said Dr. Haut. “They could pick and choose which things
they wanted. . . . Some patients only want the paper, some patients really like a
video, some patients don't want either and they want to talk to a nurse or doctor,”
he said.

Results

The group rolled out the bundle for patients on four intervention units and compared
the percentage of missed doses of VTE prophylaxis medications to that among patients
on 12 control units. The control units saw no significant change in missed doses (13.6%
to 13.3%), but the percentage of missed doses dropped from 9.1% to 5.6% on the intervention units, according to results published online in November 2018 by JAMA Network Open.

“That is a statistically significant, huge drop. It's basically over a 40%
relative reduction in missed doses of VTE prophylaxis,” said Dr. Haut, lead
author of the study and also an associate professor of surgery, anesthesiology/critical
care medicine, and emergency medicine at the Johns Hopkins University School of Medicine.

Based on that success, the program is being expanded to most of the hospital.

Challenges

The biggest challenge has been expanding the grant-funded project without any additional
full-time employees, Dr. Haut said. The solution involved convincing nurses that the
intervention improves patient care and is not necessarily extra work. “Nurses
are already supposed to educate patients—that's their job,” he said.
“I think that's probably the biggest barrier we've overcome.”

In addition, as the intervention improved communication between patients and nurses
and led to administration of more prophylaxis doses without extra notifications, the
whole process became easier, said Brandyn D. Lau, MPH, CPH, an assistant professor
of radiology and radiological science and health sciences informatics at Johns Hopkins
and senior author of the study. “It is changing practice in a way that subsequently
reduces the burden of the intervention,” he said.

One question that remains is what the role of the physician should be after a patient
declines the medication, Dr. Haut said. “That is a piece we're actively working
on. . . . It very much depends on how this medication is offered,” he said,
adding that alternative agents such as newer oral anticoagulants may be an appropriate
option in some cases.

Next steps

In addition to the expansion across the hospital, the effort has moved to Howard County
General Hospital, a community hospital within the health system, and Dr. Haut hopes
to also expand to other institutions. “We would love to partner with larger
groups to try to implement this on a larger scale,” he said, adding that patient education materials are available for free download online.

Words of wisdom

Rather than assuming that patients always receive their prescribed VTE prophylaxis
doses, physicians should communicate with nurses to verify administration and should
also tell patients why the medication is important when they prescribe it, said Dr.
Haut. “Mentioning that up front makes it a lot easier when the nurse goes in
and is explaining what each drug is for and why they're getting it,” he said.
“It's easier if they've heard about it from the doctor.”

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.